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Medicare Therapy Cap Repealed!

Taking the Cap off of Outpatient Therapy Services

Matthew Mesibov, PT, GCS
Clinical Physical Therapy Specialist

Back in 1997 congress created legislation known as The Balanced Budget Act and placed an annual and “arbitrary” financial cap on rehabilitation services reimbursement under Medicare part B. I use the word arbitrary because the decision of the total dollar amount was not based on needs related to a specific diagnosis and patient findings but due to the amount of dollars available to spend divided by the number of beneficiaries who were eligible for physical therapy, occupational therapy and speech language pathology services.  Due to federal regulations, the dollar cap which in 2017 is a shared $1980 for physical therapy and speech language pathology and $1980 for occupational therapy.

The program then included a way to apply for services beyond the financial cap if extenuating circumstances existed and were approved by the Medicare contractor.  So, picture an older adult who may have had a stroke or another neurological disease such as Parkinson’s disease or multiple sclerosis in need of necessary therapy services.  If the therapy cap was met, then you would have to check if the diagnosis qualified as an “automatic” exception vs. a manual exception.  Eventually the program changed to an exceptions process where it is up to the clinician’s clinical judgment which they must support in their documentation as to whether services should continue.

Over the years, through advocacy efforts with legislators by patients, concerned citizens, therapists and other medical professionals, congress has recognized the cap’s potential harmful effect on Medicare beneficiaries and has continually extended an exceptions process that enables Medicare to pay its share for therapy services after the patient reaches the therapy cap limits.  We almost had an elimination of the therapy cap this past year which in the 11^th hour was dropped as part of a larger legislative bill.

Move forward to Thursday, October 26, the U.S. House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee announced a bipartisan, bicameral deal on a permanent repeal of the annual outpatient Medicare therapy cap.

Here are some major points to the repeal plan:

• The Medicare Part B therapy caps would be repealed beginning January 1, 2018.
• There will be a targeted medical review process of therapy documentation beginning January 1, 2018 with the following details:
  • The dollar threshold for possible medical review targeting would be set at $3,000;
  • Therapy providers would be required to identify services exceeding the $3000 by submitting a billing code identifying this (known as the KX modifier)

Typically, when congress is going to repeal something such as the therapy cap, they will look to offset this cost by saving money elsewhere.  The current legislative proposal does not contain any offsets to pay for the provisions. As the current therapy cap exceptions is due to expire at the end of 2017, congress must act before the end of the year to either repeal the therapy caps or to grant another temporary extension for the exceptions process to protect beneficiary access to care.

We will have an answer as to whether the therapy cap comes off within the next month or so and I will be able to report on the results in our next quarterly blog.

Centrex Rehab Employee Katie J. Qualifies for World Championships!

Centrex Rehab’s very own Katie J., PTA, Anoka, competed in the US Nationals for Triathlon in Olympic Long Distance in Nebraska the weekend of August 12^th 2017.  Katie’s finish qualified her for the World Championships in 2018 in the 30-34 age group taking place in Australia!

I was able to catch up with Katie after her competition and she was gracious enough to answer some questions about competing triathlons and her awesome accomplishment.

As someone who has never competed triathlons, my curiosity was greatly peaked about what goes into competing triathlons.  Below are some of the questions I asked Katie.  The font which is italicized are Katie’s answers.

1. How long have you been a triathlete, and what drew you to competing in triathlons?
   

   I have been a triathlete for 7 years.  I was a collegiate athlete in soccer and track. After college, I was looking for something to do athletically, and 7 years ago a girlfriend asked if I wanted to do a triathlon. The triathlons give me something to do and train for.   Since that first triathlon, we usually compete in 4 – 5 triathlons together each year.

2. Was the US Nationals in Nebraska, the first US Nationals you competed in for Olympic distance?
   

   This year’s US Nationals in Nebraska was the second US Nationals I competed in.  The World championships in Australia in 2018, is the first Worlds I have qualified for.

3. Of the swimming, biking and running, do you have a favorite?
   

   Swimming is the most challenging for me as I was not a competitive collegiate swimmer. I also had to relearn how I swam in order to compete in triathlons. Biking and running are something anyone can do.

4. Do you have a particular training schedule you stick to, or does that vary?
   

   I do about 4 workouts a week normally, and amp those up 2 – 3 months before a triathlon. Weekends are for long bike rides and runs. Training biking and running together really helps lessen the “jelly legs” you get when you switch from one to another.

5. Does each course that you compete have a quirk, or all they all pretty similar?
   

   Each course is roughly.92 miles for swims, 24 – 28 miles for biking and 5-6 miles for running. Training longer distances than what I compete helps in competition. (Officially, Olympic Long Distance Triathlon is composed of a 1500 m swim, 40 k Bike ride, and a 10 K run.)

6. What are you most excited about in qualifying for the World championships next year in Australia?
   

   Everything!  The trip to Australia is going to be anniversary trip for my husband and myself. I am going to compete and then spend the next week relaxing and enjoying Australia!

Congratulations Katie and thank you very much in taking the time for the interview!  Centrex Rehab will be rooting for you in the World Championships!

written by Mary Tobias

Glow Magazine Article- Castle Peak

Centrex Rehab is pleased to share an article about Castle Peak that was published in Glow magazine about aging gracefully. Please click the below link to access the article.

Glow magazine article – Castle Peak

Utilization Management – Friend or Foe to Accessing Necessary Treatment

Matthew Mesibov, PT, GCS
Clinical Physical Therapy Specialist

Have you ever been told that you can no longer have therapy services because the insurance company is denying payment for services? If so, what may be at work is “Utilization Management”.

Utilization management (UM) was defined in 1989 by the Institute of Medicine (now the National Academy of Medicine) as “a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient-care decisions through case-by-case assessments of the appropriateness of care prior to its provision.”[1]

Though perhaps well intentioned, over the years as UM has increased, treating cost of care as an outcome metric may lead to overzealous prospective or retrospective denial of care or payment.

So, why has UM grown so much over these past few years? Upon passage of the Affordable Care Act (ACA) in 2010, health care purchasers (employers and individuals) were faced with a new set of coverage requirements and began seeking effective ways to limit the risk of potentially high financial costs. Other contributors to UM’s growth include escalating overall health care costs, increased demand for rehabilitation benefits, wide variance in care, fraud and abuse, and the medical loss ratio (the percent of the premium that an insurer spends on claims and expenses that improve health care quality, as opposed to administrative activities).

If all this seems dizzying (or more than you wanted to know), you as a consumer of rehabilitation services should know the following: typically, all health insurance payors are required to have an appeal process. This may include you as the consumer contacting them as well as your health care provider contacting the payor either by phone or by completing a form to appeal the denial decision.

The most important thing is to question your health care provider as to why services are ending if you feel it has not been explained well enough. Ask about available appeal processes if this information has not been offered. You must be a strong advocate for yourself!

[1] Institute of Medicine. Controlling Costs and Changing Patient Care? The Role of Utilization Management. National Academies Press, 1989.

This blog has been written in part based on information from the American Physical Therapy Association.

This months Solution’s Highlight is on Access Solutions!

Centrex Rehab delivers a comprehensive approach to care and has developed a broad range of therapy solutions for skilled nursing communities, housing for older adults, assisted living, hospitals, clinics, schools and other venues. This month’s solutions highlight is on Access Solutions.  Access Solutions provides universal design consulting services to promote active, safe and independent living for people of all ages and abilities. Please see the below flyer for detailed information about what Access Solutions can offer to help with independent living for people of all ages.

Centrex Access Solutions

Centrex Rehab is pleased to announce The EverActive Wellness Club was featured on the SAIL Seminar website

The SAIL Program, Stay Active and Independent for Life, is one of the evidence-based falls prevention programs that is offered through Centrex Rehab’s EverActive Wellness Club. An excerpt of the article is below:

“SAIL Seminars provided the initial training for Centrex Rehab staff in 2013.  Centrex Rehab then began to disseminate SAIL into the community in 2014, in a few independent and Assisted Living Communities through their EverActive Wellness Club.  Centrex Rehab continued to expand the number of SAIL Programs; these programs can now be found in two Skilled Nursing Facilities, as well as sixteen Independent / Assisted Living Communities.”

The full article can be found at: http://www.sailseminars.com/centrex-rehab/

Announcement: Three of Our Physical Therapists are now board certified Geriatric Clinical Specialists!

Centrex Rehab Adds Fourth Owner BEK LLC

Centrex Rehab Adds Fourth Owner BEK, LLC to Serve More Older Adults

Since launching in 2012, Centrex Rehab’s mission of providing quality-based services to enhance individuals’ abilities to live their best lives has led to rapid growth. Now, Centrex is being joined by a fourth owner and will increase the number of employees from 420 to 500. New owner BEK, LLC consists of three nonprofits: Bethany Retirement Living, Eventide Senior Living Communities and Knute Nelson, which all serve older adults. BEK will enable Centrex to expand to West Central Minnesota and Fargo, North Dakota.

“Bethany is proud to partner with Centrex Rehab due to their comprehensive approach to care and outstanding resident and patient customer service,” says Bethany Retirement Living CEO Shawn Stuhaug.

“I am extremely honored to be joining with BEK to bring rehabilitation and therapy services to more people in both rural and metropolitan areas,” adds Centrex CEO Kristy Brown. “Adding a new owner is part of our strategic plan to increase the number of people we can serve.” Earlier this year, Centrex Rehab was joined by a third owner, Volunteers of America, and was originally launched by Augustana Care and Ebenezer.

Centrex Rehab’s strategic goals include the following:

• To be a leader in the rehabilitation field with high customer satisfaction scores and offer at least one new solution to meet clients’ and patients’ needs
• To be an employer of choice offering competitive salaries and benefits, retaining at least 75% of staff members, score well on staff surveys and offer educational programs for clinical growth and attainment of educational credits several times a year
• To meet or exceed the annual budget and maximize reimbursement legally and ethically at every community
• To increase growth internally and externally using social media and marketing strategies

Because BEK offers a continuum of care for older adults involving independent and assisted living, memory care, rehabilitation, day services and more, Centrex Rehab can reach more older adults in need of housing, health care and community-based services than ever before.

Eventide President and CEO Jon Riewer is also looking forward to joining Centrex Rehab. “Eventide is excited to be working with Centrex in the delivery of therapy services for our Fargo-Moorhead and Jamestown communities,” he says. “Through a unique ownership model, this partnership allows us the opportunity to work with one of the best therapy providers in the business, expand our programming, and facilitates a more local voice in the delivery of therapy services.”

“Our mission of ‘enriching lives’ is top of mind when creating a partnership such as this one with Centrex Rehab,” says Knute Nelson President and CEO Mark Anderson. “Their reputation for providing high quality care therapy services and using best practices to do so is why they are the perfect fit for this collaboration, one that will ensure we can continue to enhance the quality of care for the individuals we serve.”

Centrex Rehab is working with BEK to achieve a smooth transition and expects most of BEK’s employees to stay on in their new roles. For more information or to interview Kristy Brown, please contact kbrown@CentrexRehab.com or (952) 495-6001.

About Centrex Rehab

Centrex Rehab provides quality based services to meet individual clients’ needs and enhance their abilities to live their best lives. Clients can find a broad range of therapy solutions for skilled nursing communities, senior housing, assisted living, hospitals, clinics, schools and other venues. As a certified rehabilitation agency, Centrex Rehab delivers a comprehensive approach to care including:

• Contract provision of full service rehabilitation: management, physical therapy, occupational therapy and speech therapy
• Staffing/recruiting to fill open positions and meet short-term or long-term staffing needs
• Management consultation
• Medicare compliance consultation
• Home modification services by certified staff to meet individual accessibility needs
• Cognitive screening/testing to allow for better case management of clients and caregivers
• Other specialty areas including wheelchair clinics, massage therapy and lymphedema specialists

Centrex Rehab allows providers to maximize efficiencies, reduce administrative costs and assure consistent, quality patient care. To learn more, visit www.centrexrehab.com or call 952-495-6000.

About BEK

BEK, LLC is a company consisting of three nonprofit organizations which serve older adults and offer housing, health care and home health services: Bethany Retirement Living, Eventide Senior Living Communities and Knute Nelson.

Volunteers of America Joins Centrex Rehab as Third Owner

Centrex Rehab is honored to announce a new development that allows the company to nearly double in size and reach more people who need care than ever before.

As of February 1, 2017, Centrex Rehab has been joined by another owner after Volunteers of America bought into the company. The main factor influencing this decision is how closely aligned the missions of Centrex Rehab and existing owners Augustana Care and Ebenezer are with that of Volunteers of America.

Joining with Volunteers of America strengthens Centrex Rehab’s mission to provide quality based services to meet individual clients’ needs and enhance their abilities to live their best lives. “We’re excited to begin this new journey as we integrate our work into Volunteers of America’s various buildings and entities across multiple states,” adds Brown.

Centrex Rehab is now able to provide services in numerous areas where the national human services provider offers independent living, assisted living and skilled nursing services. “We look forward to the relationship and engagement with Centrex and what it will bring to Volunteers of America in the changing health care world, knowing we will be stronger together,” says Volunteers of America Executive Vice President-Health Care Operations Wayne Olson.

Both organizations are working together to ensure a smooth transition and Brown anticipates that services to clients will continue without interruption. For more information or to interview Kristy Brown, please contact Jenna at jzark@CentrexRehab.com or 612-238-8552.

About Centrex Rehab

Centrex Rehab provides quality based services to meet individual clients’ needs and enhance their abilities to live their best lives. Clients can find a broad range of therapy solutions for skilled nursing communities, senior housing, assisted living, hospitals, clinics, schools and other venues. As a certified rehabilitation agency, Centrex Rehab delivers a comprehensive approach to care including:

Contract provision of full service rehabilitation: management, physical therapy, occupational therapy and speech therapy
Staffing/recruiting to fill open positions and meet short-term or long-term staffing needs
Management consultation
Medicare compliance consultation
Home modification services by certified staff to meet individual accessibility needs
Cognitive screening/testing to allow for better case management of clients and caregivers
Other specialty areas including wheelchair clinics, massage therapy and lymphedema specialists
Centrex Rehab allows providers to maximize efficiencies, reduce administrative costs and assure consistent, quality patient care. To learn more, visit www.centrexrehab.com or call 952-495-6000.

About Volunteers of America

Volunteers of America is a national, nonprofit, faith-based organization dedicated to helping those in need live healthy, safe and productive lives. Since 1896, our ministry of service has supported and empowered America’s most vulnerable groups, including veterans, seniors, people with disabilities, at-risk youth, men and women returning from prison, homeless individuals and families, those recovering from addictions and many others. Through hundreds of human service programs, including housing and health care, Volunteers of America helps almost 2 million people in over 400 communities. Learn more at www.voa.org.